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N , <br /> 1 WELUPUMP PERMIT <br /> SAN JoAQUM Cotam ExvwowmAL HEALTH DEPARTum 1868 EAST HAZELTON AVENUE-STOCI TON CA 05205- (209)4884420 <br /> NON-REFUNDAetE PERMIT CALL 209 953-7"7 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOe ADORM a CrnrrzlP <br /> Kom 10(p <br /> CROSSSTREE-JR IQ4 APN Lr(U U(JV a 10 PARCEL LA1 USE APPLICATION <br /> Oraet 41A/E <br /> PHONE 20q-,�3A- <br /> OWNER AOORess cm/sTATEfLP S <br /> 53(0 CO <br /> FACTOR PAYA I DY,I I in PHONE 2 /-�52ZC���1 2� <br /> CONTRACTOR ADDRESS V CIYISTATEfZW H&dfSt Tom' �/ / <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CTTYISTATErLP <br /> LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NutraER ll[ EXPIRATION DATE D Z <br /> DONIE"C WELL SAMPLING:9K General Mineral/Colfform Bacteria(4391)❑Dibromochioro►mopane(4392)❑Arsenic(4393) <br /> Irrrmw USE XpmesfidPrivaate ❑ krigaboNAgrkuk nal ❑tnduswal ❑water Quamy Moritoft o som sampanwamraderizeson <br /> ❑ Public water System <br /> s d 1emt tum Owr0r. Water System Nene Conrad No. or Phone Number <br /> TWE Of W= New wen ❑Replacernent Was ❑well ❑Ower <br /> 0 Monitoring Wes(s) 4 d wens ❑ Soil Borings) s°r Eairp ❑ Ceobechnical X d bortnpa <br /> ❑ Out-OSServioe Well ❑ Out-O"ervice Well Renewal ❑Cros&-lC ec0on Repair <br /> ❑New Pump ❑ Pump RepLacement ❑ Pump Repeor ❑Raise Wed Casing <br /> WELL CoNfiTN cpw <br /> Drilling Method 0K Rotary ❑Alt Rotary 0 Auger 0 Cabe Tod ❑ Push Point ❑ Other <br /> Proposed Wall pepM2(Qn ft Excavation_12" In diameter ❑ Open Bottom *Gravel P.*/Gmvel Sae it diameter <br /> ❑ C°�j Casing in darneber / Conductor Casing Depth ft <br /> Wed Casino Dlarneter W in ASTM Schad 2-on- ❑ sbeel Kpiasbc o StalNess Steel ❑Ofher <br /> Grout Baal Depth 20 O ft ❑Neat Cement(94 D bag(5.10 gel water) ❑Sand Cement sack nbdl gal water <br /> (20%safds) ❑Other <br /> —v RFGE1Vtb <br /> G—AMcUwd Pumped ❑Frea Fall ❑Other 0 Retwdant/Accelerator(none) <br /> p YtstsN , By ❑Dr" 0 Puny Contractor 0 Other <br /> ❑Coecr.te P06MW❑Dh.snaloor Widlh ft Length ft Thick 2022 <br /> in 0 Christy Boa ❑ sbom Pipe <br /> �II ❑Subum"ble❑Turbine 0 Other HP Pump Set ft Standing Water` ouu,couvry ft <br /> Plot Phu Reguiremearts: Attack a plot plu with the exact location of water well with respect to the foUd*Wg,1WM,GPS <br /> Coordinates,Property lyase, adjohabtg properties, water bodies or courses, drainage pattern,roads, Misdag wells,structures, <br /> potential sources of contanduaden,sewers or private disposal systems- Include distance from two property llues.For Domestic, <br /> Agriculture,Industrial well,provide location of any water wells or surface water witbha 200'radius of proposed well- <br /> MINIIKUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7647 <br /> DEPARTMENT USO LY <br /> rl <br /> Application Accepted By pate o ZZ Arca / Employee lQ -- <br /> G-A inspection By Data ❑ SPECIAL Well Permit <br /> Purnp inspection By Date ❑ WATM Received <br /> sal Borir>a Y,epec6om By <br /> Date- constn,a.d WoU Depth rt <br /> COLWE TS <br /> PE Sc Received CheckN Amount Dale y Invoice 9 WON of <br /> Codes info aw Cash jtwnkftd Service i <br /> 70 ab <br /> 9 S ► W <br /> L <br /> i•}�Oq-06 staTrmzt � �-b�/�Z �2 Z "l�l�i'L Z? welt r roma�: <br />